Provider Demographics
NPI:1679861710
Name:PORTER, DANIEL LEE (OTR)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:LEE
Last Name:PORTER
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3905 W ERNESTINE DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-5800
Mailing Address - Country:US
Mailing Address - Phone:618-993-6237
Mailing Address - Fax:
Practice Address - Street 1:3905 W ERNESTINE DR
Practice Address - Street 2:SUITE B
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-5800
Practice Address - Country:US
Practice Address - Phone:618-993-6237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-11
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056009406225X00000X
KYR4859225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL213486Medicare PIN